TBI management

Veneficus

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On a side note: I spent last semester in the Neuro Step down and ICU. That was by far the most depressing and challenging experience of my healthcare career.
A vegetable garden :)
 

VFlutter

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A vegetable garden :)
IMO the vegatables were in many ways the lucky ones. It is the ones who held on to just enough that got to me. The people who could no longer recognize family members, were constantly aggressive, or just followed your with their eyes and babble.
 

Handsome Robb

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I too work in the rural, with three trauma centers and a burn center about 30-40mins via helo, 2.5 by ground. For your particular call, I would have launched an aircraft, and rolled a second ambulance. All of this after recieving the first dispatch tone. Our service has a great working relationship with the area Helo EMS and they dont mind at all getting launced, and then cancelled enroute. As others have stated, its great to know that they are ten out after youve done your primary assesments.

You are correct in seeing that the pt has a head injury, however your assessment doesnt support a TBI in its entirity. When I think of a TBI, im looking for unequal pupils, MOI, possible seizures, CSF from the ears, and battle signs. With RR of 6 with periods of apnea, im curious to see how you obtained a GCS of 8...I was thinking lower. These, you state, were all clear. Another concern for me is the V/S that you obtained. They are trending for Cushings Triad, but not neurogenic shock. With Neurogenic shock, V/S will appear to be normal due to the loss of Sympathetic tone due to the spinal injury. Human nature is to have an elevated BP and Pulse due to experienceing pain, so I would be expecting to see those refelcted in my VS upon inital hook-up. I would attribute the hypotension to internal bleeding, my guess would be a hot belly, spleen...how was his pelvis?

For your pt, RSI would have been done rather quickly. Having him knocked down, allows us to control many things that would be geared with ETCO2. For this head injury pt, the target goal of 30-35 should be obtained with an 02 sat of at least 96%. All can be titrated with proper bagging and o2 admin. We would solve the pressure problem hopefully with two large bore IVs, both runnin NS or if evidence of significant blood loss, hang one line NS and the other run Ringers through blood tubing. Our Helos carry blood, so thats all ready for them if they choose to use it. From that point forward, it would be supportive until the bird arrives....as others have said....he needs a surgeon.
Where are you seeing Cushing's triad in this besides the respirations? The patient was tachycardic and hypotensive rather than bradycardic and hypertenive wit a widening pulse pressure. Although, admittedly I don't know which compensatory mechanism going to 'win' in the presence of increased ICP/impending herniation as well as hypovolemic shock.

Like vene said, everything you described is a late finding, including cushing's in it's entirety and you're behind the 8-ball if you're seeing them.

Neurogenic shock generally presents with hypotension and sometimes bradycardia...not normal vitals. The loss of sympathetic tone results in systemic vasodilation. The loss of sympathetic tone can cause bradycardia because you've effectively removed the "gas pedal" and all that's working is the "brake pedal".
 
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VFlutter

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Where are you seeing Cushing's triad in this besides the respirations? The patient was tachycardic and hypotensive rather than bradycardic and hypertenive wit a widening pulse pressure. Although, admittedly I don't know which compensatory mechanism going to 'win' in the presence of increased ICP/impending herniation as well as hypovolemic shock.

Like vene said, everything you described is a late finding, including cushing's in it's entirety and you're behind the 8-ball if you're seeing them.

Neurogenic shock generally presents with hypotension and sometimes bradycardia...not normal vitals. The loss of sympathetic tone results in systemic vasodilation.
In the first stage of increasing ICP the patient is usually tachycardic (and hypertensive). The patient only becomes bradycardic as a response to the increasing blood pressure and response by baroreceptors in the carotid. It is a reflex from the hypertension not a direct result of increasing ICP. Without the hypertension there is no bradycardia (unless there is physical distortion of the vagus nerve which is unlikely unless they are herniating). Chances are the patient's BP never got high enough to enduce the reflex.

Long story short Cushing's triad of symptoms is not always present and lack of those symptoms does not rule out increasing ICP, especially with multisystem insults. The GCS and RR are the defining symptoms in this case.

Also, Like I said before if the hypotension was neurogenic I wouldn't expect a drastic improvement with fluid especially only a liter. But it does sound like there may be a SCI component
 
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mycrofft

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History of mechanism, the huge spider web on the windscreen where his head hit and physiological signs, particularly the respiratory rate and GCS all leaf me to believe he had a TBI.
Clare's Triad. I'd add front of car demolished/steering column bent (Mycrofft's Quadrad). Alternate: interior rearveiw mirror either clearly imprinted, or actually embedded, into the face or head.

BTW, If you sit around and wait for Battle's Sign, you may be there a while, longer than the pt will live without respiration. Up to 36 hrs or, occasionally, more. A Battle's sign at the scene might be evidence of earlier trauma, or the skull will feel mushy and the pt probably deceased in short order.

Took guts to balance probable neck trauma, intolerance of oro-tracheal airway and agonal breathing, and go for the respirations at any cost over likely iatrogenic cervical insult.

EDIT:
read about the history and some of the various affects and interpretations of it (Cushing's Reflex, the mechanism indicated and create by the triad).
http://en.wikipedia.org/wiki/Cushing_reflex
 
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rexbanner

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To throw something in from left field from a logistics point of view...

I work in a rural area that gets lots of good grinders. We routinely deal with at least one major traffic collision per shift, so we've gotten pretty slick at dealing with major traumas and small-scale MCIs. What are your thoughts on immediately requesting a helicopter on initial dispatch? Case in point, last week we had a three car collision with a head-on and 7 patients (3 major, 2 moderates, 2 minors). Initially all we got was that it was an MVA, but my policy is that (since we're roughly 20 mins from a rural hospital and 90 minutes from a trauma center) I automatically request a helo. And I was glad I did, by the time we got to scene the helo was 10 out. I had to request two additional ambulances and an extra helo in all, but having that first bird nearby was great so that I could get that first-go trauma out of there so I could deal with the others.

I always advocate for early requests for resources if you're facing a potential trauma and you're a ways out from your hospital. If it turns out it's nothing major, you can always call everyone off, but early requests save a lot of time!

Our provincal EMS dispatch system has initiated a protocol for 29 Delta MVC's that if they meet specific critieria as obtained by information given by the caller, will trigger a standby or launch of STARS (medivac) directly to the scene.

I don't have any stats on this but have 'heard' that it is a huge success and drasticly reduces times.
 

shfd739

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Our provincal EMS dispatch system has initiated a protocol for 29 Delta MVC's that if they meet specific critieria as obtained by information given by the caller, will trigger a standby or launch of STARS (medivac) directly to the scene.

I don't have any stats on this but have 'heard' that it is a huge success and drasticly reduces times.
Our company's air med dispatchers sit in the main comm center and watch every call put out to the ground units. If they see a call that may benefit they'll auto launch a helicopter. Ground crew can cancel it once they get onscene. Seems to be beneficial over in that state.

The local air resource here does something similar by listening to what the county dispatches out.
 

Handsome Robb

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Our company's air med dispatchers sit in the main comm center and watch every call put out to the ground units. If they see a call that may benefit they'll auto launch a helicopter. Ground crew can cancel it once they get onscene. Seems to be beneficial over in that state.
Same here. I'm not sure if they have an "auto-dispatch" protocol or if it's the dispatcher's discretion though.

Technically we are the only people that can cancel them but if Fire marks on scene and advises they aren't needed our dispatch asks us if it's OK if they cancel. Depends on the department that's on scene and making the initial assessment. I love vollies and commend them for what they do but they cancelled our helo on a TCA OD in BFE and we ended up dropping a tube, pushing bicarb and returning code...We don't technically have to be on scene to cancel the helicopter but after that little incident I try to wait until I get on scene and do my own assessment before I decide if I need them or not.

We can request either a ground or airborne standby but until you put them on a "go" they can be diverted. Ground gets the crew to the chopper and preflighted however they do not spin up. Airborne is exactly what it sounds like, they lift and fly in the general direction of the call until they are cancelled, put on a "go" or diverted.

I listened to an interesting podcast on iTunes U the other day about HEMS and benefits. As to time you have to be >10 miles by ground and have them dispatched simultaneously with ground EMS to be faster, assuming average spin up and lift times and >45 (I'm 90% sure this was the number, I will try to find it in the podcast to be sure) miles by ground to have them be faster than ground EMS if they are requested once the EMS unit marks on scene, again assuming average spin up and lift times.
 

shfd739

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Same here. I'm not sure if they have an "auto-dispatch" protocol or if it's the dispatcher's discretion though.

Technically we are the only people that can cancel them but if Fire marks on scene and advises they aren't needed our dispatch asks us if it's OK if they cancel. Depends on the department that's on scene and making the initial assessment. I love vollies and commend them for what they do but they cancelled our helo on a TCA OD in BFE and we ended up dropping a tube, pushing bicarb and returning code...We don't technically have to be on scene to cancel the helicopter but after that little incident I try to wait until I get on scene and do my own assessment before I decide if I need them or not.

We can request either a ground or airborne standby but until you put them on a "go" they can be diverted. Ground gets the crew to the chopper and preflighted however they do not spin up. Airborne is exactly what it sounds like, they lift and fly in the general direction of the call until they are cancelled, put on a "go" or diverted.

I listened to an interesting podcast on iTunes U the other day about HEMS and benefits. As to time you have to be >10 miles by ground and have them dispatched simultaneously with ground EMS to be faster, assuming average spin up and lift times and >45 (I'm 90% sure this was the number, I will try to find it in the podcast to be sure) miles by ground to have them be faster than ground EMS if they are requested once the EMS unit marks on scene, again assuming average spin up and lift times.
Sounds similar to us. Fire can launch and cancel. Fire tends to over launch as do some of our crews. It's kinda fun to get onscene and cancel the standby or go by ground of the helo is still a certain amount of time away cuz the volley just insists they be flown.

It kills me to hear the helo be put on a flying standby and they have a 25-30 min eta to the scene when the unit is 20 mins away. Just put the person in your unit quickly and go ground. At that point there is no overall time saved so why tie up that air resource. the flight crew burns up the time difference during load/unload.

Those times sound about right. Ive been told to estimate flight time at 2 miles/min which usually factors in enough launch time. Most of the time around here helos are overused but some folks just insist that patients have to be flown.
 

mycrofft

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For some reason I was thinking about naso-tracheal intubation not a NPA


Link to article at the bottom of the page
http://www.impactednurse.com/?p=2235

I know you can not get ICP without a bolt but you can make an assumption based off signs/symptoms. It sound like increased but not yet herniation. Also, bradycardia is typically present with neurogenic shock but not always.
Nasal glioma IS exceedingly rare. However, such mistubations if you will have been known in anterior facial GSW's;l I bet if someone crammed yor nasal septum and associated cartilages hard enough anterior to posterior with a steering wheel, you might rupture the cribiform plate.

Bet it lessened ICP though! (ewww)
 

Merck

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Exactly, signs of Herniation. No where did I say that I would wait and not do anything until I saw these signs. These are things that Im going to be expecting my pt to demonstrate while in my presence if im going down a TBI road with a significant head bleed. If, in fact, you do have those late signs than thats a whole different ball game. Trying to maintain a perfusing pressure without worsening the herniation is key. read: 190/110. That, of course is not solved with NS infusions, but labetalol. Im sure im preaching to the choir on this subject.
Can't really jump on board with you here. Treatment of a TBI with a BP of 190/110 might not necessarily call ofr the use of labetalol. We use labetalol when indicated but that is usually with an SAH. TBI has different considerations and not all ICP is created equal. With no way of knowing what our ICP is then all we are really doing is guessing at what the 'ideal' MAP might be. Perhaps the MAP with 190/110 (around 136) is exactly what the brain needs. Autoregulation of CBF is not always disrupted in TBI and throwing labetalol at it may cause harm.

On the OP not sure that I would have necessarily gone for much head movement to facilitate airway control either and you do want to be careful with the NPA. RSI would likely have been indicated but one has to be considerate of the danger regarding a sat of less than 90 in TBI.

The question of hypotension with a possible concurrent injury is difficult. Competing interests like these are hard to manage in the field. Boluses of N/S to try to maintain a pressure may be just as harmful in other ways if there is trauma/major bleeding, but you do want to maintain a systolic of at least 90. This can be a case where pressors could be used in trauma - not something normally advocated.

I recommend (if it hasn't been said already in this string - I'm tired and generally lazy) that folks review the Brain Trauma Foundation guidelines, both for prehospital and hospital care. Nice evidence-based approach.

KCCO
 
OP
Clare

Clare

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Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.

Backup has its benefits but also drawbacks; backup takes time and it is often significantly quicker to just take the patient to the hospital with an early RT call placed to the hospital before leaving the scene if the patient has a life threatening, time critical problem such as traumatic brain injury, cardiogenic shock or life threatening asthma. With the progressive upskilling of the Paramedic the requirements to actually need an Intensive Care Paramedic is becoming less, they are nice to have as they generally come with decades of experience dealing with very sick people are deal with sick people a lot however it is a balance of risk. For this bloke yes, RSI and titrate ETCO2 would be most beneficial however I feel a good airway and oxysaturation was obtainable without RSI and that it was much faster to take him to the hospital rather than call for backup. In hind sight if he had deteriorated significantly I would have been kind of screwed.

Despite reassurances I still feel significantly unsure about this patient; not because what I decided was "wrong" or harmful but that this is the first time I have encountered major trauma in somebody who is otherwise young and healthy and only a little younger than myself; I guess I've had a couple of people lately who have either died or committed suicide and I have been thinking a bit more about the quality of life, or rather lack of it, that some people have had and that this young guy for all intents and purposes might have had the opportunity to experience all the good things in life taken away from him and I'd hate to think that any part of that was due to what I decided.

Guess they don't prepare you for this stuff at uni eh?
 

medicsb

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Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.
Just curious, are ICPs not automatically dispatched for certain calls? Are the fire fighters able to request them if they think they're needed or do they have zero medical training? I would think requesting an ICP on contact would give them time to get on scene while extrication is being performed. Overall, I agree if you can get to the hospital sooner than an ICP can get to you, then by all means do so.
 

Veneficus

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, but you do want to maintain a systolic of at least 90. This can be a case where pressors could be used in trauma - not something normally advocated.
I respectfully disagree.

It is my position that maintaining a number simply to do so has no point.

As I understand pressors in hemorrhagic shock likely will have no effect and can actually be harmful.

Furthermore, if you have an active hemorrhage, even with and especially, a BP below 70sys, adding water at best will do nothing and adding pressors on top of the physiologic response is also likely to do nothing at all, and possibly cause harm.

I realize there is the feeling of "needing to do something" but doing something to do something is a treatment for the provider, not the patient.
 

Veneficus

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Both calling for a helicopter and an Intensive Care Paramedic with RSI would have taken significantly longer than just driving him to the hospital; he was 30 minutes by ground and at least twice as long by air; for the helicopter to be dispatched, prepare, fly, land, load, fly to the hospital and unload would take an hour; likewise for an Intensive Care Paramedic with RSI to respond, locate, intubate and then still have to drive to hospital would be probably an hour as well.

Backup has its benefits but also drawbacks; backup takes time and it is often significantly quicker to just take the patient to the hospital with an early RT call placed to the hospital before leaving the scene if the patient has a life threatening, time critical problem such as traumatic brain injury, cardiogenic shock or life threatening asthma. With the progressive upskilling of the Paramedic the requirements to actually need an Intensive Care Paramedic is becoming less, they are nice to have as they generally come with decades of experience dealing with very sick people are deal with sick people a lot however it is a balance of risk. For this bloke yes, RSI and titrate ETCO2 would be most beneficial however I feel a good airway and oxysaturation was obtainable without RSI and that it was much faster to take him to the hospital rather than call for backup. In hind sight if he had deteriorated significantly I would have been kind of screwed.

Despite reassurances I still feel significantly unsure about this patient; not because what I decided was "wrong" or harmful but that this is the first time I have encountered major trauma in somebody who is otherwise young and healthy and only a little younger than myself; I guess I've had a couple of people lately who have either died or committed suicide and I have been thinking a bit more about the quality of life, or rather lack of it, that some people have had and that this young guy for all intents and purposes might have had the opportunity to experience all the good things in life taken away from him and I'd hate to think that any part of that was due to what I decided.

Guess they don't prepare you for this stuff at uni eh?
Trauma is a disease of the young.

Arguably it is the most important disease in society because it takes from society producers and people with thier lives ahead of them.

One of the things that I often wonder about is the seperation of pediatric and adult trauma. From the physiologic developmental point, most trauma is in people who are not fully developed yet. Shouldn't a trauma expert be more familiar with a developing human and then perhaps a geriatric than "healthy adults"?

It vexes me.
 

Merck

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I respectfully disagree.

It is my position that maintaining a number simply to do so has no point.

As I understand pressors in hemorrhagic shock likely will have no effect and can actually be harmful.

Furthermore, if you have an active hemorrhage, even with and especially, a BP below 70sys, adding water at best will do nothing and adding pressors on top of the physiologic response is also likely to do nothing at all, and possibly cause harm.

I realize there is the feeling of "needing to do something" but doing something to do something is a treatment for the provider, not the patient.
Vene,

Fair enough to disagree if that is your inference from my statement. However I am quite aware of the fallacy of treating a number. My point here by stating a systolic of 90 in TBI is that it is a generally supported and evidence-based goal. It has been shown that hypotension less than 90 systolic is profoundly detrimental in TBI and that's where my stance comes from.

I totally agree that pressors in trauma are generally verboten, but my inclusion of them here is only in support of managing the TBI. A fluid-restrictive approach with no pressors might save the patient from the hypovolemia but to what end if they're a vegetable and/or die from the brain injury?

Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation.AUBrain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DWSOJ Neurotrauma. 2007;24 Suppl 1:S7.

Cheers
 

Smash

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Notwithstanding the BTF guidelines, the data to support cerebral perfusion pressure in TBI is very sketchy. The BTF appears to me to deal primarily with isolated head injury. The polytrauma patient or patient with uncontrolled hemorrhage is a very different beast. Pressors seem to me to do pretty much the polar opposite of what we really want to achieve. We may be able to increase CPP for a time, but it will be at the cost of increased bleeding and probably of decreased cerebral blood flow.
What limited animal data there is on these sorts of 'patients' shows worse outcomes with both early fluid resuscitation and with the use of pressors.

Alspaugh, D.M., Sartorelli, K., Shiffer, C., & Nees, A.V. (2000) Prehospital resuscitation with phenylephrine in uncontrolled hemorrhagic shock and brain injury. J Trauma. 48(5)

Bourguignon, P. R., Shackford, S. R., Shiffer, C., Nichols, P., & Nees, A. V. (1998). Delayed fluid resuscitation of head injury and uncontrolled hemorrhagic shock. Archives of Surgery, 133(4), 390-398.
 

Merck

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I totally agree that pressors in trauma are not ideal and I'm not advocating their use. However we end up transporting people for hours to a tertiary centre and sometimes you have to play a difficult game of balancing the competing interests in a polytrauma case.

There is also a wealth of studies out there that support the prevention of hypotension in TBI. The method of dealing with the prevention is subject to consideration of other injuries. As to the reference I think it is a pretty big leap to extrapolate 'simulated' pre-hospital pig findings into on-car clinical practice. As well, the first study states that mortality was lowest in the phenylephrine group with secondary injury increasing. Still not ideal either way.
 

mycrofft

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Despite reassurances I still feel significantly unsure about this patient; not because what I decided was "wrong" or harmful but that this is the first time I have encountered major trauma in somebody who is otherwise young and healthy and only a little younger than myself; I guess I've had a couple of people lately who have either died or committed suicide and I have been thinking a bit more about the quality of life, or rather lack of it, that some people have had and that this young guy for all intents and purposes might have had the opportunity to experience all the good things in life taken away from him and I'd hate to think that any part of that was due to what I decided.

Guess they don't prepare you for this stuff at uni eh?
No they don't. Just keep concerned and current in your skills and keep giving considered, professional feedback to your superiors about what works and what doesn't.

An army recruit was undergoing the old exercise where they had to dig a hole as a tank approached and jump in, letting the tank pass over. The drill sergeant had advice for them: keep your head down and if you dig a good hole, the tank will take care of itself.

In other words, quality of life will be a product of severity of insult, time to your arrival, then the rest of the stuff you can affect. Do your part, if you stop to worry or to identify with the pt you may not be able to do that...or not for very long.
 

Akulahawk

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Just reading the initial description of the patient, I'd say that the patient is in a very bad way, and given the circumstances, I don't think much of what you could do with what you had available would have made him any better. Honestly, I don't think you made him any worse, significantly.

I also have the impression that there's three (minimum) issues going on.
The patient has at the minimum:
1) TBI - likely a severe/high grade concussion, possibly even diffuse axonal injury, if the patient doesn't have a frank bleed in the cranial vault. In any case, I'm not seeing signs of impending herniation/increased ICP yet. I don't think that this patient will survive long enough to herniate anyway.
2) SCI - High possibility of SCI. Starred windshield... Some what I see looks like neuro shock from SCI. While I don't necessarily have proof of this, I'm very suspicious of it.
3) Internal bleeding - again, from the heavily starred windshield - this tells me that the patient was likely unrestrained or poorly restrained. This leads me to think that the patient impacted elsewhere quite forcefully, thus leading to significant internal injury.

Clearly we're seeing signs of shock. Given my suspicions, I'm going to want to maintain BP at a level indicated for shock from a traumatic injury rather than what might be indicated for TBI. I think the TBI will be the least of the patient's immediate problems.

Do I have any studies at hand to back up my position? No. Just going off what I see and previous education.

Honestly, I would be surprised if the patient survives.
 

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